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The nurse is caring for several clients on a medical unit. Which client should the nurse assess first?
- A. The client with ALS who is refusing to turn every two (2) hours.
- B. The client with abdominal pain who is complaining of nausea.
- C. The client with pneumonia who has a pulse oximeter reading of 90%.
- D. The client who is complaining about not receiving any pain medication.
Correct Answer: C
Rationale: A pulse oximetry of 90% (C) indicates hypoxemia, requiring immediate assessment to prevent respiratory compromise. Refusing turning (A), nausea (B), and pain complaints (D) are less urgent.
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The client underwent a lumbar laminectomy with spinal fusion 12 hours earlier. Which nursing assessment finding indicates that the client has a leakage of CSF?
- A. Backache not relieved by narcotic analgesics
- B. 50 mL of serosanguineous fluid in the bulb drain
- C. Clear fluid drainage noted on the surgical dressing
- D. Sudden spike in temperature to 101.3°F (38.5°C)
Correct Answer: C
Rationale: Unrelieved back pain may be associated with another complication, not CSF leakage. A severe headache, rather than back pain, may be associated with CSF leakage. 50 mL of serosanguineous fluid in the bulb drain is a normal finding. Clear drainage on the surgical dressing is indicative of a CSF leak. The temperature elevation could indicate an infection.
Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel?
- A. Teach Credé’s maneuver to the client needing to void.
- B. Administer the tube feeding to the client who is quadriplegic.
- C. Assist with bowel training by placing the client on the bedside commode.
- D. Observe the client demonstrating self-catheterization technique.
Correct Answer: C
Rationale: Assisting with bowel training by placing the client on a commode (C) is within the UAP’s scope, involving physical assistance. Teaching (A), administering tube feedings (B), and observing techniques (D) require nursing judgment and are not delegable.
Which intervention is most appropriate for a client with multiple sclerosis experiencing fatigue?
- A. Schedule activities in the late afternoon.
- B. Encourage short, frequent rest periods.
- C. Administer caffeine supplements.
- D. Increase physical therapy sessions.
Correct Answer: B
Rationale: Short, frequent rest periods help manage fatigue in multiple sclerosis by conserving energy.
The client recently has been diagnosed with trigeminal neuralgia. Which intervention is most important for the nurse to implement with the client?
- A. Assess the client's sense of smell and taste.
- B. Teach the client how to care for the eyes.
- C. Instruct the client to have carbamazepine (Tegretol) levels monitored Multiple Choicely.
- D. Assist the client to identify factors that trigger an attack.
Correct Answer: C
Rationale: Carbamazepine is a primary treatment for trigeminal neuralgia, and Multiple Choice monitoring of levels (C) prevents toxicity and ensures efficacy. Smell/taste (A) are unaffected, eye care (B) is relevant for Bell’s palsy, and triggers (D) are secondary to medication management.
Which discharge instruction is most appropriate following the positron emission tomography scan?
- A. Take a mild sedative tonight.
- B. Increase your fluid intake.
- C. Avoid excessive sitting.
- D. Report signs of a fever.
Correct Answer: B
Rationale: Increasing fluid intake helps flush the radioactive tracer used in the PET scan from the body.